Analysis of risk factors for postpartum depression after cesarean section in women with early-onset preeclampsia

Abstract

BACKGROUND

Early-onset preeclampsia significantly increases maternal and fetal morbidity and mortality. Many pregnant women with early onset preeclampsia choose cesarean section as their delivery method. Although extensive research has explored the association between postpartum depression (PPD) and cesarean section, few studies have investigated the risk factors after cesarean section in women with early-onset preeclampsia.

AIM

To examine these risk factors through a retrospective, observational analysis of 287 women who underwent a cesarean section for early preeclampsia between June 2014 and March 2024.

METHODS

Participants were assessed in person during the 32^nd week of pregnancy, 2 days post-cesarean, and 6 weeks postpartum. According to the Edinburgh Postnatal Depression Scale (EPDS), participants who underwent cesarean section were divided into PPD (n = 60) and non-PPD groups (n = 227). Furthermore, PPD was diagnosed at 6 weeks postpartum according to depressive symptoms (EPDS score ≥ 11). The demographic and clinical features of PPD were screened. Multivariate logistic regression analysis was used to identify PPD risk factors.

RESULTS

The prevalence of PPD was 20.9% (60/287) among the 287 women who underwent cesarean section for early-onset preeclampsia. Multivariate logistic regression analyses revealed that advanced age (age > 40 years) [odds ratio (OR) = 1.93, 95%CI: 1.31-2.82], previous preeclampsia (OR = 7.15, 95%CI: 5.81-8.85), pre-pregnancy obesity (OR = 2.42, 95%CI: 1.62-3.63), gestational diabetes mellitus (OR = 3.52, 95%CI: 2.51-4.92), preexisting hypertension (OR = 1.35, 95%CI: 1.03-1.89), PPD symptoms (EPDS ≥ 11) at 2 days postpartum (OR = 6.15, 95%CI: 1.32-28.35), high prenatal self-rating anxiety scale score (OR = 1.13, 95%CI: 1.06-1.18), and pain at 6 weeks postpartum (OR = 2.16, 95%CI: 1.28-3.66) were independently associated with PPD.

CONCLUSION

Risk factors for PPD after cesarean section in women with early-onset preeclampsia include advanced age (age > 40 years), pre-pregnancy obesity, previous preeclampsia, gestational diabetes mellitus, preexisting hypertension, PPD symptoms (EPDS ≥ 11) at 2 days postpartum, prenatal anxiety, and pain at 6 weeks postpartum. The early identification of these factors and interventions can mitigate the risk of PPD.

Key Words: Postpartum depression; Cesarean section; Early-onset preeclampsia; Depression; Depressive symptoms; Risk factor

Core Tip: Early-onset preeclampsia leads to considerable maternal and fetal morbidity and mortality. Many pregnant women with early onset preeclampsia opt for cesarean section as their delivery method. Although extensive research has explored the association between postpartum depression (PPD) and cesarean section, few studies have investigated the risk factors of PPD after cesarean section in women with early-onset preeclampsia. We found that the risk factors for PPD after cesarean section in women with early onset preeclampsia included advanced age, prepregnancy obesity, previous preeclampsia, gestational diabetes mellitus, preexisting hypertension, PPD symptoms at 2 days postpartum, prenatal anxiety, and pain at 6 weeks postpartum. The early identification of these factors and interventions can mitigate the risk of PPD.

INTRODUCTION

Preeclampsia is the most prevalent and critical obstetric complications, affecting approximately 35% of all pregnancies[1]. The hallmark clinical manifestations of preeclampsia include simultaneous onset of hypertension and proteinuria[2]. Additionally, pulmonary edema, severe headache or visual disturbances, upper abdominal pain, acute renal failure, liver damage, thrombocytopenia, and hemolysis[3]. If left untreated, preeclampsia may progress to convulsions/epilepsy (eclampsia) in the most severe cases[4]. Early-onset preeclampsia refers to the occurrence of preeclampsia before the 34^th week of gestation and often indicates early onset and a severe course of the disease[5]. Population studies have demonstrated the detrimental effects of early-onset preeclampsia on the well-being of mothers and children. Notably, women exhibit a heightened susceptibility to diabetes, hypertension, coronary artery disease, and stroke, and children face an increased risk of metabolic and cardiovascular diseases[6]. Therefore, early onset preeclampsia not only imposes a severe economic burden on society and families but also places a significant mental strain on pregnant women. Furthermore, early-onset preeclampsia appears to increase the risk of postpartum depression (PPD)[7].

PPD is prevalent in mothers after childbirth. The incidence of PPD varies significantly across regions, with rates ranging from 0% to 60%[8]. PPD is most commonly diagnosed between 4 weeks and 12 weeks postpartum[9] and is characterized by depressed mood, anhedonia, irritability, restlessness, anxiety, agitation, and impaired concentration[10]. A recent study revealed that more than 16% of pregnant and postpartum Chinese women develop depression[11]. The effects of untreated PPD on mothers and infants can have a profound impact on children's cognitive, emotional, and behavioral well-being. Additionally, PPD increases the mothers' risk of self-harm or suicide[12]. Therefore, screening mothers for PPD symptoms and identifying modifiable risk factors during the perinatal period is vital for promoting the health of mothers and their children.

Previous surveys have identified psychosocial and medical risk factors for PPD, including antenatal anxiety and depression, history of anxiety, child-rearing stress, poor social support, stressful life events, conflict in marriage or poor relationships with partners, being less educated, emerging from a lower stratum of society, and maternal and infant complications[13]. Other risk factors associated with obstetric delivery have also been identified, including induced labor, mode of delivery, and placenta previa. Despite rising rates of cesarean sections worldwide, mounting concerns regarding PPD and its procedures have been observed. Currently, most pregnant women with early-onset preeclampsia undergo cesarean sections[14]. Therefore, further research focusing on PPD and cesarean section in women with early-onset preeclampsia is required.

Over the last three decades, epidemiological studies have examined the relationship between cesarean sections and PPD in the previous three decades[15]. However, few studies have individually surveyed the risk factors of PPD after cesarean section in women with early-onset preeclampsia. Therefore, additional investigations are warranted to identify PPD in women with early onset preeclampsia undergoing cesarean section to facilitate timely diagnosis and intervention. This study aimed to investigate the correlation between clinical indicators and PPD and identify autonomous factors that contribute to PPD in patients undergoing cesarean section for early-onset preeclampsia.

MATERIALS AND METHODS

Ethics statement

At the time of recruitment, women with preeclampsia who underwent cesarean sections signed an informed consent form for future research using their biological samples, interview information, and medical records. The hospital's Scientific Council and Ethics Committee approved this study.

Study population

We retrospectively enrolled 287 women with early onset preeclampsia who were hospitalized and underwent cesarean section at our hospital between June 2014 and March 2024. In-person visits were conducted at three distinct time points for data collection: At the 32^nd week of pregnancy, 2 days after cesarean section, and 6 weeks after cesarean section (Figure 1). Clinical information was collected from medical records, referral letters, and direct patient inquiries regarding obstetric and medical histories and medication use. According to the International Society for the Study of Hypertension in Pregnancy, early onset preeclampsia is diagnosed before 34 weeks of pregnancy[16]. After a cesarean section, all women were followed up by a psychiatrist 6 weeks after discharge if PPD was suspected.

Figure 1 Selection process of participants. PPD: Postpartum depression.

The inclusion criteria were adherence to the diagnostic criteria for early-onset preeclampsia[16], the availability of complete clinical data and follow-up information, the age range of 18–45 years, and the cesarean section prior to the onset of labor.

The exclusion criteria were multiple pregnancies or cerebral disease (e.g., trauma or surgery to the brain), missing clinical data and follow-up information, and the use of pain medications for the treatment of chronic pain.

PPD status

This study aimed to explore the associations between different sociodemographic and clinical factors and the occurrence of PPD at 6 weeks postpartum in women who underwent cesarean section for early-onset preeclampsia. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used to assess PPD in large-scale studies. The EPDS comprises a 10-item survey in which each question is rated from 0 to 3. The EPDS score increases with symptom severity. While a threshold of 9 or 10 is recommended for identifying PPD, a score of 11 optimizes the overall sensitivity and specificity. Thus, in this study, PPD was defined as the presence of depressive symptoms (EPDS score ≥ 11) at 6 weeks postpartum. We classified EPDS scores of ≥ 11 as indicative of symptomatic depression, thereby classifying individuals into the PPD category. Those with EPDS scores of < 11 were classified as non-PPD. Fear of childbirth was evaluated in the 32^nd week of pregnancy using the Wijma Delivery Expectancy/Experience Questionnaire Version A (W-DEQ)[17].

Data collection

Patients with comorbidities or conditions that might impede risk factor assessment were excluded. This retrospective study collected demographic and clinical data including age, obesity pre-pregnancy (body mass index ≥ 30.0 kg/m²), smoking during pregnancy, marital status, previous preeclampsia, medical payment, gestational diabetes mellitus, preexisting hypertension, scores on antenatal self-rating anxiety scale (SAS) and self-rating depression scale (SDS), social support rating scale (SSRS) scores, uterine contraction pain, surgical scar pain, numeric rating scale (NRS) for pain of uterine contraction, fear of childbirth at week 32 (W-DEQ), EPDS score at 2 days postpartum, pain levels at 6 weeks postpartum, pain interfering with daily activities, pain disturbing sleep quality, and the necessity for pain medication. An NRS score of three was established as the threshold for postpartum pain[18]. The participants were contacted 6 weeks before the survey. Those who declined the in-person study visits were deemed lost to follow-up. We analyzed the correlation between clinical parameters and PPD in women undergoing cesarean section for early-onset preeclampsia. Our study utilized well-validated Chinese versions of the EPDS[19], NRS[20], SDS[21], SAS[22], W-DEQ[17], and SSRS[23].

Sample size

Multivariate logistic regression analysis was used to identify risk factors for PPD among the 20 variables (Table 1). Following the classical methodology outlined in the article on event-per-variable simulation studies in logistic regression analysis, no significant issues were observed with the parameter estimation and conventional significance testing of the logistic model when the event-per-variable values equaled or exceeded 10 or 15, respectively. Therefore, in our study, a sample size of 200–300 was deemed sufficient to obtain statistically significant results. Finally, 287 women were included in the analysis.

Table 1 Comparison of baseline data among postpartum depression and non-postpartum depression groups, n (%).

Variable	PPD (n = 60)	Non-PPD (n = 227)	P value
Mean age (years, SD)	32.5 ± 4.2	31.8 ± 5.1	0.329
Ethnicity	Chinese (100)	Chinese (100)	/
Parity
Nulliparous	27	90	0.453
Multiparous	33	137
Maternal age (years)
≤ 40	36 (60.0)	186 (81.9)	< 0.001
> 40	24 (40.0)	41 (18.1)
Obesity pre-pregnancy ≥ 30.0 kg/m2
Yes	15	193	< 0.001
No	45	34
Smoking during pregnancy
Yes	3	2	0.811
No	57	225
Marital status
Married	55	208	0.935
Single or divorced	5	19
Previous preeclampsia
Yes	34	11	< 0.001
No	26	216
Medical payment
Medical insurance	52	196	0.198
Self-paying	8	31
Maternal comorbidities
Gestational diabetes mellitus	11 (18.3)	20 (8.8)	0.035
Preexisting hypertension	3 (5.0)	37 (16.3)	0.025
Antenatal self-rating anxiety scale (median, IQR)	35.0 (7.5)	31.0 (6.5)	< 0.001
Antenatal self-rating depression scale (median, IQR)	33.0 (11.0)	30.0 (9.0)	< 0.001
Antenatal social support rating scale	4 (6.5)	20 (9.0)	0.761
Fear of childbirth week 32 (Wijma Delivery Expectancy/Experience Questionnaire Version A)
Low score (< 85)	8	30	0.782
High score (≥ 85)	52	197
Postpartum variables at 2 days
Pain of uterine contraction	4 (68.3)	12 (53.3)	0.037
Pain from surgical scar	50 (83.3)	160 (70.5)	0.046
Numeric rating scale for pain of uterine contraction (mean, SD)	2.9 (2.5)	2.7 (2.4)	0.321
EPDS score (median, IQR)	4.1 (5.0)	3.2 (3.1)	0.004
Postpartum depressive symptoms			< 0.001
Edinburgh Postnatal Depression Scale ≥ 11
Postpartum variables at 6 weeks
Pains at 6 weeks postpartum	30 (50.0)	61 (26.9)	< 0.001
Pain impacting daily activities	16 (26.7)	29 (12.8)	< 0.001
Pain disturbing sleep quality	11 (18.3)	18 (7.9)	< 0.001
Need for pain medication	5 (8.3)	9 (4.0)	0.037

PPD: Postpartum depression; IQR: Interquartile range.

Statistical analysis

All analyses were performed using Statistical Package for the Social Sciences version 26 (IBM Corp., Armonk, NY, United States). A continuous variable is the mean ± SD or the median (interquartile ranges). Pearson’s coefficient was used to test the correlation between categorical and continuous variables. Categorical variables were expressed as n (%). Continuous variables were compared using the Student's t-test, and categorical variables were compared using the χ² or Fisher's exact test. The risk factors for PPD were identified using multivariate logistic regression analysis. Using bivariate correlation analyses, factors that were significant in the univariate analyses (P < 0.05) or deemed clinically significant were assessed for collinearity. Statistical significance was set at P-values less than 0.05.

RESULTS

Patient demographics

Of the 362 recruited participants, 345 (95.3%) completed the second questionnaire at the hospital, and 287 (79.3%) underwent postpartum visits. A loss-to-follow-up rate of 20.7% was observed ​(Figure 1). A total of 287 women with early onset preeclampsia who underwent a cesarean section were included in the final analysis. Among the 287 women, 60 (20.9%) were included in the PPD group (EPDS score ≥ 11), and 227 were included in the non-PPD group (EPDS score < 11). Table 1 provides detailed data on the PPD and non-PPD groups.

The proportion of individuals aged > 40 years was significantly higher in the PPD group [40% (24/60)] than in the non-PPD group [18.1% (41/227); P < 0.001]. Pre-pregnancy obesity, history of eclampsia, gestational diabetes, and hypertension were significantly prevalent in both groups. No significant differences were noted between the groups (P < 0.001). Prenatal SAS and SDS scores were higher in the PPD group than in the non-PPD group (35.0 vs 31.0, 33.0 vs 30.0, P < 0.001). However, the difference in prenatal SSRS scores between the two groups was not significant. No significant differences in smoking during pregnancy, marital status, or medical payments were observed between the two groups.

Intraoperative and postoperative characteristics

Table 1 shows the intraoperative and postoperative characteristics of the patients. Within 2 days of the cesarean section, the proportion of women with uterine contraction pain and surgical scar pain was higher in the PPD group than in the non-PPD group. Notably, the EPDS score 2 days after the cesarean section was higher in the PPD group than in the non-PPD group (P = 0.004). The proportion of patients with EPDS scores ≥ 11 before discharge was also higher in the PPD group compared to that in the non-PPD group (P < 0.001). At 6 weeks postpartum, 50.0% of the women in the PPD group and 26.9% of the women in the non-PPD group reported pain (P < 0.001). The PPD group reported experiencing more pain and taking pain medications more frequently than the non-PPD group (P < 0.001). Fear of childbirth at week 32 (W-DEQ) and NRS scores for uterine contractional pain did not differ significantly between the groups.

Analysis of independent risk factors for PPD by multivariate logistic regression

Multivariate logistic regression analysis was conducted to identify potential risk factors associated with PPD based on factors that significantly differed in the demographic and clinical characteristics of women with early onset preeclampsia who delivered via cesarean section. Table 2 lists the odds ratio (OR) of various factors associated with EPDS scores ≥ 11. Multivariate logistic regression analyses demonstrated that age > 40 years (OR = 1.93, 95%CI: 1.31-2.82), previous preeclampsia (OR = 7.15, 95%CI: 5.81-8.85), pre-pregnancy obesity (OR = 2.42, 95%CI: 1.62-3.63), gestational diabetes mellitus (OR = 3.52, 95%CI: 2.51-4.92), preexisting hypertension (OR = 1.35, 95%CI: 1.03-1.89), PPD symptoms (EPDS ≥ 11) at 2 days postpartum (OR = 6.15, 95%CI: 1.32-28.35), high prenatal SAS score (OR = 1.13, 95%CI: 1.06-1.18), and pain at 6 weeks postpartum (OR = 2.16, 95%CI: 1.28-3.66) were independently associated with PPD. The OR values are shown in Figure 2.

Figure 2 Forest plot of risk factors for postpartum depression at 6-week postpartum. A: Forest map of antenatal factors associated with postpartum depression (PPD); B: Forest map of postpartum variables at 2 days associated with PPD; C: Forest map of postpartum variables at 6 weeks associated with PPD. SDS: Self-rating depression scale; SAS: Self-rating anxiety scale; OR: Odds ratio; PPD: Postpartum depression.

Table 2 Risk factors for postpartum depression after cesarean section in women with early-onset preeclampsia.

Variable	P value	Odds ratio	95%CI
Age > 40 years old	< 0.001	1.93	1.31-2.82
Pre-pregnancy obesity	0.048	2.42	1.62-3.63
Previous preeclampsia	0.016	7.15	5.81-8.85
Gestational diabetes mellitus	0.032	3.52	2.51-4.92
Preexisting hypertension	< 0.001	1.35	1.03-1.89
Antenatal self-rating anxiety scale	0.036	1.13	1.06-1.18
Antenatal self-rating depression scale	0.93	1	0.96-1.05
Postpartum variables at 2 days
Pain of uterine contraction	0.19	1.33	0.86-2.05
Pain from surgical scar	0.06	2.08	0.96-4.32
EPDS score	0.45	1.06	0.91-1.18
Postpartum depression (EPDS ≥ 11)	0.03	6.15	1.32-28.35
Postpartum variables at 6 weeks
Pains at 6 weeks postpartum	0.04	2.16	1.28-3.66
Pain impacting daily activities	0.46	1.37	0.62-2.65
Pain disturbing sleep quality	0.97	1.03	0.47-2.28
Need for pain medication	0.98	0.96	0.35-2.42

EPDS: Edinburgh Postnatal Depression Scale.

DISCUSSION

Globally, the number of pregnant women with early onset preeclampsia is increasing, with varying degrees of impact on maternal and newborn health[24]. Women considered to be at high risk for early onset preeclampsia should be referred for preconception counseling to identify modifiable risk factors. The association between early-onset preeclampsia, cesarean section, and PPD has garnered significant attention. A meta-analysis of 32 studies identified a significant association between cesarean sections and PPD[25]. However, no studies have examined the risk factors of PPD in patients undergoing cesarean section. Therefore, this study included women with early onset preeclampsia who underwent cesarean section to identify the risk factors closely related to PPD.

In this study, the age > 40 years, pre-pregnancy obesity, previous preeclampsia, gestational diabetes mellitus, preexisting hypertension, PPD symptoms (EPDS ≥ 11) at 2 days postpartum, high prenatal SAS score, and pain at 6 weeks postpartum were independently associated with PPD.

The EPDS is the most commonly used screening tool for major depression among postpartum women. A recent meta-analysis demonstrated that an EPDS cutoff score of ≥ 11 points maximized the combined sensitivity and specificity for detecting PPD[26]. Therefore, an EPDS score of ≥ 11 points may be the optimal cutoff value for maternal depression. In this study, an EPDS score of ≥ 11 points at 6 weeks postpartum was defined as PPD[26]. The prevalence of PPD in our study was 20.9% (60/287), consistent with the results of previous studies[27].

Currently, no ideal preventive measures are available for PPD in women who undergo cesarean section for early-onset preeclampsia. Timely identification of high-risk factors in this population would allow timely prenatal counseling to identify modifiable risk factors. This study identified several factors independently associated with PPD. Advanced age, defined as age > 40 years[28], emerged as a significant predictor. This aligns with prior research suggesting that older mothers may face increased psychological challenges during the transition to parenthood because of the biological, psychological, and social changes associated with advancing age[29]. Moreover, pre-pregnancy obesity is a risk factor for PPD. Research suggests that obesity can lead to chronic inflammation and hormonal imbalance, which may affect mood regulation and increase the risk of depression. In addition, obese women may experience more complications during pregnancy and childbirth, leading to increased stress and anxiety, both of which are known contributors to PPD[30,31]. Given the growing prevalence of obesity worldwide, this association underscores the need for comprehensive prenatal and postpartum care to address physical and mental health concerns.

Our findings also revealed that previous preeclampsia, gestational diabetes mellitus, and preexisting hypertension were independently associated with PPD. Gestational and mellitus are associated with metabolic dysregulation and can lead to increased levels of stress hormones, such as cortisol. Elevated cortisol levels have been linked to mood disorders, including depression. Furthermore, managing a chronic condition during pregnancy can increase psychological stress, potentially exacerbating the risk of developing PPD[32]. Preexisting hypertension is a significant risk factor for PPD. Women with a history of hypertension may experience heightened physiological stress during pregnancy, leading to increased anxiety and mood disturbances. Chronic stress associated with hypertension management contributes to emotional dysregulation. Additionally, complications arising from hypertension, such as preeclampsia, can exacerbate feelings of fear and uncertainty regarding maternal and fetal health, thereby increasing the likelihood of developing PPD[33]. These complications in pregnancy not only pose physical risks but also contribute to psychological stress, increasing the likelihood of PPD. This finding aligns with previous studies that emphasized the need for comprehensive prenatal care to identify and manage the aforementioned conditions, thereby reducing the risk of PPD[34].

The results of a longitudinal study evaluating postpartum EPDS scores demonstrated that high EPDS scores at week 1 predicted the risk of PPD[35]. In contrast, another study revealed that women who underwent cesarean section had higher total EPDS scores than those who underwent vaginal delivery 2 days postpartum[36]. Similar to the results of previous research, our findings also demonstrated that women with PPD reported high EPDS scores and significant depressive symptoms at 2 days postpartum. An EPDS score of ≥ 11 was predictive of PPD. Because PPD is challenging to treat, early detection and intervention are required.

In a prospective cohort study, anxiety and depression during pregnancy were identified as important factors contributing to PPD[37]. Cheng et al[38] have suggested that anticipatory anxiety during pregnancy could be a potential predictor of symptoms of PPD. This study used the SDS and SAS during the 32^nd week of pregnancy to evaluate depression and anxiety. The findings demonstrated a notable correlation between high SDS and SAS scores and PPD during the preliminary analysis; however, only the SAS score remained significantly associated with PPD when accounting for all other variables. Therefore, heightened anxiety symptoms during pregnancy are recommended as prenatal risk factors for PPD. The study also demonstrated that pain at six weeks postpartum was individually linked to PPD. Although pain is common during the postpartum period, its impact on mental health has often been overlooked. Therefore, the integration of psychological support and pain management strategies into routine postpartum care may mitigate the risk of PPD.

In addition, research conducted in Western populations has shown that women who undergo cesarean sections, particularly those with preexisting medical conditions, are at a higher risk of PPD. Weingarten et al[39] found that women with a history of mental health issues and those who experienced complications during delivery were more likely to develop PPD, which is similar to our findings in women with early-onset preeclampsia.

However, several limitations hamper the ability of this study to identify PPD risk factors accurately. First, the cohort consisted exclusively of Chinese women with singleton pregnancies, limiting the diversity of the sample. Second, the EPDS was used by non-psychiatrists rather than psychiatrists to diagnose PPD. Although the EPDS is a widely used tool for screening PPD with an estimated sensitivity of 80%, it is not a substitute for professional psychiatric diagnoses. Third, our study had a relatively high loss-to-follow-up rate of 20.7%. This attrition may have affected the robustness of the findings. Additionally, this study was a retrospective and not a prospective randomized controlled trial. Future researchers could observe the offspring's long-term development, encompassing both physical and neurological aspects, for six months or longer. Finally, while our current study primarily focused on cross-sectional data collected at these time points, we acknowledge that incorporating longitudinal analysis methods could provide deeper insights into the temporal dynamics of PPD risk factors. Notably, the limitations of our dataset prevented us from conducting such analyses. However, we recognize the importance of this approach and will consider it in future studies. Future research should aim to minimize loss to follow-up and include diverse populations to enhance the applicability of the findings across different ethnic groups and cultural contexts. This would help us understand the broader implications of PPD and its risk factors, ultimately contributing to more effective prevention and intervention strategies tailored to various populations.

CONCLUSION

In conclusion, the results of this study suggest that advanced age (age > 40 years), previous preeclampsia, pre-pregnancy obesity, gestational diabetes mellitus, preexisting hypertension, PPD symptoms (EPDS ≥ 11) at 2 days postpartum, prenatal anxiety, and pain at 6 weeks postpartum may be intimately related to an elevated risk of PPD after cesarean section in women with early-onset preeclampsia. Early detection of PPD risk factors and provision of interventions can reduce the risk of PPD after cesarean section in women with early onset preeclampsia.

Routine screening for risk factors, including prenatal anxiety and a history of preeclampsia, should be performed during prenatal visits. Utilizing validated tools, such as the EPDS, can help identify women at an elevated risk of developing PPD, enabling timely intervention. Additionally, Clinicians should establish comprehensive pain management plans personalized to the needs of each patient, combining pharmacological options (e.g., analgesics) with non-pharmacological approaches (e.g., physical therapy and relaxation techniques). Effective management of postpartum pain can enhance recovery and decrease the risk of PPD. By implementing these recommendations, healthcare providers can take proactive steps to reduce risk factors associated with PPD in this vulnerable population.